Методы деривации мочи после радикальной цистэктомии при раке мочевого пузыря: осложнения и качество жизни (обзор литературы)

Subcutaneous Urinary Diversion: An Alternative to Percutaneous Nephrostomy

The Rectosigmoid Bladder as a Method of Urinary Diversion

To compare the health-related quality of life of elderly patients after radical cystectomy for bladder cancer in urinary diversion groups: ileal conduit, ureterocutaneostomy, or orthotopic urinary reservoir. The 109 participating elderly patients aged 75 or older completed self-reporting questionnaires: the QLQ-C30, and on satisfaction with urinary diversion methods. Fifty-six patients had undergone constructions for ileal conduit diversion, 31 for ureterocutaneostomy, and 22 for orthotopic urinary reservoir (OUR). The median follow-up period for each group was 4.0 years (range 0.3-11.2), 4.5 years (range 0.3-18.0), and 3.3 years (range 0.3-6.7), respectively. Regardless of the type of urinary diversion, the majority of patients reported having good overall quality of life, although with some problem of pain. No significant differences among urinary diversion subgroups were found in any quality of life area in the QLQ-C30 questionnaire. More patients in the OUR sub-group felt disappointment than those in the ileal conduit or cutaneostomy sub-groups. However, a questionnaire which asked which diversion method would be preferable showed a trend that more patients in the OUR subgroup would have chosen the same one. Health-related quality of life appeared relatively good in these 3 groups. Patient demands and expectations may be so different from the results that the details of each urinary diversion method should be explained thoroughly. OUR construction could be a candidate even for elderly patients.

Evolution of the Rectal Bladder as a Method for Urinary Diversion

SIMPLE cystectomy has proved to be a satisfactory method of treatment for carcinoma of the urinary bladder. We became interested in this method of treatment in 1948 and have performed 265 cystectomies since then. During the period between 1948 and 1953, ureterosigmoidostomy was utilized as a means of urinary diversion. Since then, we have been using the ileal loop as a method of urinary diversion. In our opinion, the morbidity has been decreased and the prognosis for long term survival is definitely enhanced because of improvement in the method of urinary diversion. In our original series reported in 1956, a total of 48 five year cases was analyzed. In this group, there were 2 operative deaths, an operative mortality of 4.2%. Thirty patients died within the five-year period and sixteen survived five or more years, a survival rate of 33.5%. Incorporated in this series was a large number of patients operated upon early in our experience. The criteria for surgical removal were not well formulated, and cystectomy was performed in many cases in whom there was no possibility of ultimate cure. With additional experience, we have developed more rigid indications for cystectomy, resulting in an improvement in five-year survival rates. Cystectomy is now performed on patients in the following categories: lesions of high grade cellular malignancy (Grade III and IV); biopsy evidence of muscle invasion; rapid recurrence of tumours of increasing cellular malignancy; and generalized involvement of the bladder mucosa by tumour, not controllable by other means. Cystectomy has not been performed in those patients in whom, on abdominal exploration, the following conditions were found: extravesical spread of tumour; the presence of positive pelvic lymph nodes; the presence of metastatic disease outside the pelvis. The presence of palpable lymph nodes, demonstrated to contain carcinoma by frozen section, is definitely an indication for palliative diversion without any further surgery on the bladder. In our experience, patients with positive lymph nodes do not survive beyond a year. We do not feel that there is any particular advantage in routinely combining radical lymph node dissection with the cystectomy. The lymph node dissection seems to add materially to both the mortality and morbidity of the surgery; and, since the prognosis is extremely poor if positive nodes are present, it is our belief that the rare case who might be salvaged by this method is more than offset by the added mortality and morbidity involved. A recent review of 99 patients followed five or more years after cystectomy and ileal loop diversion showed an overall survival rate of 40 (41.4%). The immediate operative mortality was 4.2%. An analysis of this group based on both Broder's classification and Jewett's classification is of interest.

To investigate the outcome of Mainz Pouch II urinary diversion for both malignant and non-malignant diseases. A retrospective analysis. Kilimanjaro Christian Medical Centre, Institute of Urology, Moshi, Tanzania from April 1995 to May 2007. Mainz Pouch II was created in 83 patients of which, 38 were females and 45 were males (M:F 1.2:1). Early complications were seen in 11 (13.2%) patients, as follows: one (1.2%) prolonged ileus, 1(1.2%) wound dehiscence, two (2.4%) perioperative deaths among the malignant group, seven (8.4%) superficial wound sepsis. Long term complications were seen in 14 (16.9%) patients, as follows: one (1.2%) patient developed an incision hernia, one (1.2%) patient developed unilateral pyelonephritis, one (1.2%) patient developed unilateral ureteral stenosis, two (2.4%) patients had deterioration of renal function, three (3.6%) patients developed mild to moderate unilateral hydronephrosis, three (3.6%) patients developed mucoceles. Among the 83 patients in this series, three (3.6%) patients developed metabolic acidosis, two (2.4%) of which, required oral bicarbonate supplementation. All (100%) patients had daytime continence while three (3.6%) patients had occasional night time incontinence. Overall total continence was achieved in 80 (96.4%) of the patients. The Mainz Pouch II is a safe and reproducible method of urinary diversion and serves as a satisfying method of continent urinary diversion in all age groups. This reconstructive surgery enabled the afflicted to achieve personal goals, hopes and aspirations, positively influencing their quality of life. The follow up show low complication rate with good results in terms of continence and quality of life, however, long term results remain to be evaluated.

ObjectivesWe aimed to compare health‐related quality of life (HrQoL) in patients who underwent ileal conduit (IC) vs orthotopic neobladder (ONB) as a method of urinary diversion (UD) after radical cystectomy (RC) for invasive bladder cancers.MethodsThe questionnaires of the Functional Assessment of Cancer Therapy‐Bladder Cancer (FACT‐BL) were used to evaluate and compare the HrQoL in 113 patients with 1 year follow‐up.ResultsForty‐nine patients were included in the ONB group and 64 patients in the IC group. Patients with IC showed superior scores in all domains of the FACT‐BL questionnaire and this reached statistical significance in physical well‐being (PWB), functional well‐being (FWB), over all FACT‐G, Bladder‐Specific Subscale and FACT‐BL total scores (P‐values = .01, .01, .001, .001, and .001, respectively).ConclusionsOur findings demonstrate marginally improved HrQoL in IC patients when compared with patients undergoing ONB which may be attributed to an increased morbidity and postoperative complications in the ONB group.

Longitudinal Health Related Quality of Life After Open Radical Cystectomy: Comparison of Ileal Conduit, Indiana Pouch, and Orthotopic Neobladder

The Kock pouch as a urinary reservoir: Pitfalls and perspectives

PD60-02 LONGITUDINAL HEALTH RELATED QUALITY OF LIFE AFTER RADICAL CYSTECTOMY: COMPARISON OF ILEAL CONDUIT, INDIANA POUCH, AND ORTHOTOPIC NEOBLADDER

IN 1935, Seiffert¹reported in a German surgical journal a procedure of bilateral ureteral transplantation into a segment of intestine as a method of supravesical urinary diversion. It remained, however, for Eugene Bricker, MD, 15 years later to modify and popularize the procedure which we now know as the ileal loop.²The ileal loop was presented originally as a relatively simple method of urinary diversion which hopefully would overcome the many pitfalls of nephrostomies, cutaneous ureterostomies, and ureterosigmoidostomies. Since 1950, this method has been widely used to treat a large variety of urologic and surgical conditions requiring urinary diversion. Reports have appeared in the literature at intervals outlining the experience of groups or individuals with this operation and containing various modifications to the original procedure. The present study, comprising 120 cases, reports the 10 year experience with ileal loop diversion in the University Hospitals of Cleveland and its

AimTo report on a simple and rapid method of urinary diversion. This method was applied successfully in different clinical scenarios when primary reconstruction of the ureters was not possible.Materials and methodsThe disconnected ureter is catheterized by a feeding tube. The tube is secured with sutures and brought out to the lateral abdominal wall as cutaneous tube ureterostomy (CTU).ResultsThis method was applied in three different clinical scenarios: a 40-year-old man who sustained multiple high-velocity gunshots to the pelvis with combined rectal and bladder trigone injuries and massive bleeding from a comminuted pubic fracture. Damage control included colostomy and bilateral CTUs. A 26-year-old woman had transection of the right lower ureter during abdominal hysterectomy. Diagnosis was delayed for 3 weeks when the patient developed sepsis. The right kidney was diverted with a CTU. A 37-year-old male suffered from bladder perforation and hemorrhagic shock. Emergency cystectomy was done and urinary diversion was accomplished with bilateral CTUs. In all cases, effective drainage of the urinary system was achieved with normalization of kidney function.ConclusionWhen local or systemic conditions preclude definitive repair and damage control surgery is needed, CTU provides fast and effective urinary diversion.

Radical cystectomy today is considered one of the most complex and morbid surgical interventions in urology. The application of a minimally invasive approach to radical cystectomy has grown, and excellence centers have published series in which laparoscopic radical cystectomy (LRC) is associated with lower morbidity and equivalent short–term oncologic results [1]. To date, neobladder substitution has been selected increasingly in high–volume centers, whereas the ileal conduit has been a standard method of urinary diversion after radical cystectomy. Although it is well accepted that radical cystectomy with subsequent urinary diversion is associated with marked complications, there have been limited studies comparing the perioperative and intraoperative findings between the ileal conduit and neobladder [2]. The authors have written an article about the comparison of two urinary diversion methods after laparoscopic radical cystectomy [3]. LRC is a challenging procedure with many benefits if performed in an experienced center. Another issue with LRC involves the decision about which urinary diversion to choose. Although a neobladder seems more acceptable for the patient, it has its own risks during the operation and in the follow–up period. It also takes more time to construct, even in open surgery [2]. This article is the first in the literature to compare these two diversion methods in laparoscopic surgery. A comparison was made of 63 patients: ileal conduit and neobladder in 39 and 24 individuals respectively. The patients were not randomized and it is difficult to say that the number of patients is sufficient to make a healthy comment about the features of the two techniques. The patient demographics, operative time, conversion rate, blood loss, transfusion rate, morphine analgesic requirement, length of hospital stay, complication rates, follow up, and quality of life assessments were compared between the two groups. They found no difference between age, BMI, smoking history, transurethral resection of bladder tumor pathology result, blood loss, blood transfusion requirement, conversion rates, length of hospital stay, morphine requirement, complications, or follow–up and quality of life. This shows that the two techniques have almost the same features regarding these parameters. It is interesting that there is no difference in the two groups regarding the quality of life parameter. We, in fact, think that neobladder is performed to increase the patient's quality of life. Of course, the authors mention that it is not a randomized study, with a low quantity of patients and low quality of statistical power. The neobladder procedure took longer to perform than the ileal conduit. It is an expected finding as neobladder construction is more challenging and secondary patients existed in this group. As a conclusion, the study is valuable, because it is the first one that compares neobladder and ileal conduit diversions after laparoscopic radical cystectomy, but further randomized and larger studies are required to get clearer information about the differences between these two methods.

Selection of the Type of Urinary Diversion in Conjunction with Radical Cystectomy

Background. Treatment of patients with bladder cancer remains one of the most pressing problems of oncourology. It is important to understand that the risks caused by the radical cystectomy are determined not only and even not so much by the technical difficulties of removal of the bladder, as by the somatic status of the patient who needs cystectomy. It is important to understand that radical cystectomy and urine derivation are essentially two stages of a single surgery intervetion. However, in the publications describing postoperative cystectomy complications often ignore the fact that the maximum number of complications develops and is associated with the complexity of the urinary diversion method. In a relatively recent long-term study on the results of radical cystectomy, the authors reported a 3% postoperative mortality rate and a 28% level of early postoperative complications (within 3 months after surgery). The authors paid attention to the fact that late complications was more often caused by the urinary diversion methods, whereas early complications are more often associated with radical cystectomy. In general, it is determined that morbidity and mortality are lower the more experience the clinic staff and the surgeon have in terms of patient management. The combination of these factors causes a slower recovery and a longer postoperative day. Despite the decrease in mortality, the level of complications of this procedure remains high even in the best centers of the world. Objective. Assessment of the prerequisites for the development of complications after radical cystectomy using different methods of urine diversion. Materials and methods . Oncological treatment results of 458 patients with bladder tumors were subjected to a detailed analysis. Results. The number of patients with comorbidities was significantly pronounced and noted in practically every patient (381 patients - 83.1%). At the same time, it was found that in the whole group of patients the average value of the Charlson's comorbidity index corrected for age turned out to be 2.6 ± 1.6 (from 0 to 8). Early postoperative complications were detected in 197 patients (43.0%). Early complications NOT associated with urinary diversion prevailed - 36.2%, while the frequency of early complications associated with urinary diversion was statistically significantly less on average 3 times and amounted 12.9%. The incidence of late postoperative complications (associated and NOT associated with the derivation of urine) was generally lower compared to early complications by almost 5 times (9.1%). At the same time, unlike the early postoperative period, among the late postoperative complications, mainly complications associated with the urine diversion of were recorded in 6.5% of cases. It is important that in the studied group of patients were recorded predominantly mild and moderate degrees of complication (Clavien-Dindo I-II) and amounted 41.7%. Conclusion. Obviously, radical cystectomy with urinary diversion are complex surgery with expected high rates of postoperative complications. In this regard, these indicators along with functional and oncological results should be taken into account when discussing a treatment strategy. Early postoperative complications are mainly related to technique of radical cystectomy performing, whereas late complications are more often due to used method of urinary diversion, while high indicators of the planned long-term survival indicate that it is not necessary to perform radical cystectomy. Thus, our findings unequivocally confirm the opinion of international experts and most researchers that achieving optimal optimal results in performing radical cystectomy with urinary intestinal diversion, maximizing morbidity and postoperative lethality is possible only with the accumulation of sufficient experience in this operation types.